C-Section: Errors and delays increasing death, causes fistula

After her regular pregnancy months, 19-year-old Deborah Vershima, had expected the delivery of her baby to be smooth. She is however fortunate to have escaped death last year after she was badly butchered by a doctor during a caesarian section (CS) delivery at a clinic in Benue state.

Recounting the harrowing details of her near-death CS experience in 2016, Vershima said: The experience was the most discomforting I ever had. Yet, her baby came out, stillborn.

She disclosed that the incident happened at a private clinic in Kastina-ala, Benue state after she had been in labour for four days. It was then her doctor recommended she should have an emergency CS to save both her life and her baby’s.

“At first, the doctor tried to make me deliver the baby naturally. But after four days, the doctor finally realise it could not deliver naturally and the baby was already distressed. So he cut me open and brought out the baby. It was very painful because there was no anaesthesia.”

“And to make matters worse, The baby was born dead. Still, after the CS, the wound refused to heal; pus and blood kept gushing out from the spot of incision that was sutured very badly. Despite that I stayed in the hospital for three weeks, still the wound couldn’t heal,” she said.

“After some time, I started leaking both urine and faeces from my vagina”, Deborah said amid tears, depicting a condition known as recto-vaginal fistula (RVF).

However, she is lucky to be repaired free of charge at Ogoja General Hospital, Cross River State, through the support of the USAID fistula care plus project.

To preserve a mother and her baby’s life, medical doctors often recommend Emergency Caesarian Section (ECS) as an urgent intervention for women when it is medically risky to deliver naturally. When required, medical experts noted that ECS must be carried out timely and personnel to carry it out be fully prepared to prevent any form of complications. It must also be carried out in a medical theatre with all the facilities on the ground.

Another salient aspect gynaecologists advise is that it must be done with the full consent of the woman or her family. However, where the necessary cautions are not taken into consideration and not done timely or properly, risks involved could result in harm or death to either the mother, the baby or both.

Where an ECS is performed by an unskilled doctor or a quack, as what could have possibly been the case in Vershimas case, it can be deduced that the doctor, either did not do his job on time or did it well, thereby causing harm to the mother and leading to the loss of her child.

Such cases of medical negligence have continued to occur during CS in health facilities on daily basis.
For instance, In Lagos State, one woman Mrs Chiamaka De-frietas, died early in 2017 after a C-section at an A-class private hospital in Lagos. According to the autopsy report, her bladder had been cut during the surgery causing some internal concealed bleeding.

Another woman, Kemi Fadehan, also died during childbirth at a public hospital in Lagos, Ifako-Ijaiye General Hospital, after a mismanaged CS. Her bereaved husband, Lanre Fadehan, said the doctors had reportedly cut his wife’s intestine in error during the operation to bring out his baby. He said the complication was not detected early because it was concealed leading to internal bleeding.

Still, in another private hospital, a woman just named Mrs Kemi told the reporter that she lost her baby because the doctors delayed in carrying out a CS on her.

She said: The nurses found out that the baby was breached and the umbilical cord was protruding. Because there was no doctor on the ground to attend to me, I was forced to endure 24 hours of labour. By then, the baby had become distressed and it was apparent I needed urgent CS. By the time I was finally operated on, the baby had gotten weak and was stillborn, she lamented.

Reports show that other cases abound with tales such as scissors, gauze and other surgical items forgotten inside a woman’s womb. Further reports show incidents of the punctured intestine, delayed and denied emergency response leading to complications such as obstetric fistula, infections, bleeding and, eventually, death.

Speaking on the array of cases, a University of Calabar Teaching Hospital (UCTH), Obstetrician and Gynecologist, Dr Nelson Egwu, explained the possible reasons why incidents of negligence happen.

He told the reporter, “when a woman has been in labour for long and a doctor is supposed to offer quick intervention but no necessary medical items like oxygen, blood, drugs and several others are readily available, this will cause delay in emergency response. In a public hospital, however, blames for such lapses cannot be placed at the doors of the doctors but mostly hospital management who are saddled with the responsibility of making sure these necessities are in stock at every point needed.”

Another challenge is that, in a government hospital, there is often a shortage of doctors on duty to attend to many emergency cases breaking out. In some instance, a doctor can be attending to one ECS case and another patient who may need the attention of the same doctor, seem neglected. This is what often causes a delay in emergency response.
However, where scissors or other instruments are forgotten inside a patient, that is a clear criminal offence. And it is often the fault of the health worker who is in charge of such instrument. And when a trained doctor or health worker is supposed to do his work but neglects to do it without any clear reason, then it becomes an act of negligence, he said emphatically.

Dr Egwu added that Nigeria is improving in terms of CS procedures, but the government still needs to train more doctors on surgical skills.

He said: Government needs to provide needed facilities for emergency obstetric services such as oxygen, blood and drugs and also reduce the cost of CS.

Dr Egwu, also explained that complications can occur during and after a CS or ECS delivery, sometimes do to some unknown reasons, and also due to a patient delaying in coming to the hospital or consenting to the CS.

He explained further that During a CS, infection or bleeding can occur, and the anaesthetics could cause loss of consciousness. Also after a CS, if the vessels are not tied very well, it can cause bleeding where the bladder and intestines are punctured.

The UCTH Obstetrician and Gynecologist said where such complications, clearly an act of negligence on the part of the hospital or health worker causes harm to the patient, the victim can seek for redress in a court of law.

Explaining the code of medical ethics in Nigeria, an attorney who has handled such cases, Barr. Chinaedu Uba said a doctor can be liable for medical malpractice in negligently performing a c-section or in reverse, for negligence in not performing a C-section, only when he agrees to treat the patient.

“Upon agreeing to treat the patient, the doctor must do his best within a reasonable time, to save the patient. If a patient presents any of the risk factors that would suggest a C-section is necessary and the doctor agrees to perform the C-section, he has the responsibility to do it at the best of his ability and timely”, he said.

Dr. Stella Iwuagwu, Director Centre for The Right to Health (CRH), said that a victim of such medical malpractice or the family may report any form of malpractice to the office of the chief medical director of the hospital involved, or follow the procedure set out by either Ministry of State Commissioners of health or hospital services.

She explains that the victim can report directly to the Medical and Dental Council of Nigeria (MDCN) in the form of an affidavit or sue in a regular court where there is a substantial case against the medical practitioner.

“Consequently, damages may be awarded according to the degree of harm perceived by the court and in the event of questionable death, a complaint can be written to the Minister and Commissioner of Health. Also, an autopsy can be conducted on the deceased body,” she said.

Also narrating her encounter is another victim of negligence, Ada Odita. She told the reporter how she was denied ECS at a private hospital in Lagos because she didn’t have the initial deposit demanded by the hospital.

She said: The hospital refused to operate on me because I didn’t have the money for deposit. Because of that, my labour was prolonged and my baby was born dead. I also developed a tear in my bladder.

For patients like Ada who had been denied ECS because of money, Dr. Iwuagwu, said this is a violation of the National Health Act (NHA) 2014, Section 20, which states that: (1): “A healthcare provider or health worker shall not refuse a person emergency medical treatment for any reason whatsoever…all patients, regardless of their means or health challenges shall have the right to be treated in an emergency without discrimination. A violation of this right is punishable by a fine of N100,000 or imprisonment for up to six months”.

Unfortunately, victims lack of awareness of their health rights and lack of desire to seek redress ,are part of the challenges hindering prosecution of cases. Other challenges mentioned are; the cost of redress, access to records, illiteracy, time lapse, evidence tampering and undue delay in getting justice, among others.

An anonymous staff of the Medical and Dental Council of Nigeria (MDCN), explained that a victim of medical negligence can seek redress through the council.

However, the only snag, he said, is that: The process takes time because the law stipulates the time-frame for each of the stages; from when the complaint was received, to when the doctor responds and when the panel members all doctors and dentists review the case individually. From there, it proceeds to the disciplinary tribunal for trial if majority of the doctors vote that the doctor has a case to answer.

He also pointed out that due to the delay by the Federal Government in constituting the investigating panel of the MDCN, about 70 cases is still pending before the disciplinary tribunal, a situation he says frustrates their ability to dispense with cases and punish erring doctors swiftly.

Efforts of Lagos State Government in fighting maternal death in Lagos facilities and medical malpractices:

According to the Assistant Director, Health Facility Monitoring and Accreditation Agency (HEFAMAA), Lagos Ministry of Health, Dr. Iboma Godswill: “If a woman receives obstetrical care in a facility and got injured or died in the process and we are informed, we will go and investigate and find out if the person that performed the procedure has the liscence to practise as a gynecologist.

The person agrieved can also write to the Honorable commisioner, the permanent secretary, or to executive secretary HEFAMAA, stating your grievances and you case will be taken up. After investigating, if it is necessary to report the issue to the MDCN, or to the relevant bodies, we will refer the case for appropriate sanction. If we find out that the medical doctor is not registered with the MDCN, he will be prosecuted and the facility sealed up”.

The Director Family Health and Nutrition, Lagos Ministry of Health, Dr. Folashade Oludara, explains the process of maternal death auditing in the state.

“When a woman dies in Lagos hospital while giving birth, whether through CS or normal delivery, we take audit, to find out why such things happen and we try to resolve the issue. This is done through a process known as Maternal and Perinatal Death Surveliance Response(MPDSR). Through the MPDSR, we identify the three delays, she could be delayed at home, or on the way, maybe the health facility is very far from her. The delay may happen at the health facility- we find out if she was unnecessarily delayed at the hospital.

“If the fault is from the health facility, we call our health workers together and then we solve it, if it has to do with buying of equipment, the government will spring into action and buy the equipment. We started the MPDSR in 2013 with just the Maternal Death Review (MDR), but now we have included babies because we want to find out why babies will die within one month of birth. Through the help of MamaYe organisation, we are now trying to digitalize the process.”

Today, in most hospitals, about 50 percent of deliveries are surgical, which is why there is need for ECS to be done on time and according to required medical standard.

A Public Health Physician, Dr. Arigbidi Stephen, explained that CS procedure is life-saving for the mother, her baby or both. He said: Initially, we used to have assisted-delivery such as vacuum and or forceps deliveries. but most of these assisted deliveries are obsolete now because of’ some damages that can be done to the mother or baby, which is why we advise that women should go for surgery when there is need.

“When we talk about CS, it is important for it to be time-precise in order to avoid damage to the mother, baby or both. In obstetric fistula for instance, over 90 percent of the cases are caused by prolonged obstructed labour, which can happen when the mother has a contracted pelvis, or there’s a problem if the baby is big or she has no strength to push.”

He added that Prior to now, our people put so much importance on vaginal delivery. That is why when a woman labours so much and finally delivers, she is commended. But this is not supposed to be, pregnancy is supposed to be a normal physiology activity. It should not be tedious. This is why there should be CS when labour becomes tedious, he said.

Stephen also laments a situation in which, according to him, Very few of our woman attend antenatal care (ANC). When women attend ANC, threatening issues can be picked on time and many of their cases can be detected early and properly managed.

He then listed some reasons for CS as; “When a woman has her first child above the age of 35, she can be advised to go for CS to prevent getting distressed, short women with small pelvis require CS if the baby is too big, hypertensive women to avoid the baby being distressed, as well as if a babys head refuses to come out within twelve hours of labour, among others.”

Sad as these cases are, and with more occurring by the day, Nigerias maternal deaths keep rising. To halt and reduce the trend, Dr. Stephen said Nigerias government needs to have a legislature for Emergency Obstetrical Care, adding that Our government should legislate that any woman in labour should be treated whether they have money or not.”

According to a National Health Demographic Health Survey (NDHS 2013), Up till now, Nigeria still has one of the highest maternal mortality rates in the world with 576 per 100,000 life births, and many of these deaths occur after a C- section delivery.”